This article reviews the present state of small-diameter vascular substitution, the mechanisms of graft failure and the ongoing matters of graft design, with particular attention to small-caliber grafts. Tissue engineering of blood vessels with the mechanical properties of native vessels and with the antithrombotic properties required is really a great challenge. Recent advances, however, indicate that the goal of providing a tissue-engineered vascular graft that will remain patent in vivo for substantial periods of time, is achievable. This review describes the specific requirements of the successful replacement artery from a biomaterial- and tissue-engineering perspective, as well as various approaches in vascular tissue engineering including cells and cell sources, scaffolds and their improvements as well as bioreactors and signaling.